Project Part 2: Performance Gap

Purpose

This assignment is intended to help you learn to do the following:

Distinguish performance improvement gaps.
Summarize process improvement concepts, principles, and strategies in a healthcare organization. (III.A.4.ii)
Critique performance management concepts, principles, and strategies in a healthcare organization. (III.A.4.i)
Recommend a performance improvement implementation plan and strategies.

Overview

This assignment represents Part 2 of a two-part project that you will complete for your ePortfolio. As you work on this assignment, you will be developing the following Commission on Accreditation of Healthcare Management Education (CAHME) competencies:

III.A.4 Critical Thinking, Analysis, & Problem Solving

Performance Management
Process Management

Action Items

Complete Exercise 7: Improving a Performance Gap in my Organization (p. 301) in your textbook. (attached below)
Prepare your assignment for submission:
Follow all applicable APA Guidelines Links to an external site. regarding in-text citations, list of cited references, and document formatting for this paper. Failure to properly cite and reference sources constitutes plagiarism.
Write 3-4 pages paper. The title page and reference list are not included in the page count for this paper.
Proofread your assignment carefully. Improper English grammar, sentence structure, punctuation, or spelling will result in significant point deductions.
Submit your assignment. Your work will automatically be checked by Turnitin.

CHAPTER

USING IMPROVEMENT TEAMS AND TOOLS

Learning

Objective

After completing this chapter, you should be able to

• identify strategies for creating improvement project teams;
• describe the role of managers in team decision making;
• differentiate how, when, and why to use common improvement tools;

and
• recognize what tools are best to use at each step of an improvement

project

T he nursing shared leadership committee in a midsize hospital came up
with a great idea for improving the work environment for bedside
nurses, who spend time in face-to-face group meetings that take them

away from patient care duties. The committee proposed using electronic
message boards to reduce the need for these meetings. The nurses could use
this medium to complete some group work during their downtime rather
than depart from units to attend formal meetings. This change would
potentially help nurses be more productive at the bedside and improve the
way they get their work done. The electronic message boards could also be
used to update everyone on the work of various committees and share
evidence-based practice recommendations.

The information technology department set up electronic message boards
for each unit, and nurses were instructed on how to use the medium and its
purpose. However, what seemed like a great idea did not catch on with the
bedside nurses. Simply making this new communication tool available was not
enough to get people to start accessing the board to interact with one another.
The value of using the message boards for communication was unclear to people
at the grassroots level, and face-to-face meetings had been their usual way of
interacting for years. The committee chairs, charge nurses, and clinical leaders
were not made responsible for regularly posting content on the message boards.
The staff nurses quickly stopped logging into the message boards when they
found very little to read.

Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017

ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-02-08 00:23:25.

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Applying Qual i ty Management in Healthcare: A Systems Approach23

This change effort failed for several reasons. First, and most important,
it was initiated with a top-down approach. The electronic message boards may
have been a great idea; however, the frontline nurses were not engaged in the
improvement project. The idea was pushed down from the upper levels of
the nursing department, and the message boards were designed without any
input from staff. Whether the frontline staff considered improved productivity
and enhanced communication to be important goals was never fully explored
before implementation.

Often, improvement projects result in people being asked to change the
way they have always done things—thus, a bottom-up, team approach is more
likely to be successful. This chapter describes how managers can reduce the
likelihood of unsuccessful improvement projects. The first step is to charter
the project, which involves clearly defining the project goals and scope. Next,
the members of the improvement project team need to be carefully chosen.
This chapter also discusses the various improvement tools that will be used by
the team to understand the current process and select the best interventions
for achieving the performance improvement goals.

Charter Improvement Projects

Before embarking on an improvement project, the manager or managers in
the departments or units affected by an improvement project should establish
clarity about the project scope (areas affected) and purpose (desired outcome).
The more issues clarified up front, the less likely the team will be to experience
false starts. A written project charter is essentially a contract between the
organization’s management and the improvement team.

The project leader and the sponsoring manager(s) may jointly create the
chapter, or it may be created at the first team meeting. Issues that should be
addressed in creating the project charter include these (Rohe and Spath 2005):

• Purpose: In one or two sentences, describe the purpose of the project.
The brief explanations should define, in specific terms, what the project
is expected to achieve.

• Objectives: List some of the measurable outcomes of the project. The
objectives should answer the questions, “How will we achieve our
purpose?” and “What are the signs of success?”

• Deliverables: What are the tangible milestones anticipated along the
way? What are the progress points that can be expected? When defining
deliverables, include dates—they add commitment and urgency to the
project completion.

Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-02-08 00:23:25.

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Chapter 12: Using Improvement Teams and Tools 231

• Team and team resources: Identify the people and resources needed to
analyze, create, and carry out the purpose.

• Success factors: These are the essential elements outside the team
needed to make the project successful, such as buy-in from the staff or
financial resources.

A typical charter consists of a one-page summary of critical details of
the project, allowing all stakeholders to agree on the goals to be achieved, the
scope, the time line, and the resources needed for the project to be successful.
Exhibit 12.1 illustrates a project charter template.

Project Title

Purpose

What are we trying to
achieve?

Objectives

What are we trying to
achieve? How will we know
we got there?

The new/redesigned process will (be specific):

•
•
•

Deliverables

What must be done to
achieve the objectives?

The team is expected to complete the following:

By __/__:

Team and Resources Core project team members:
Leader:
Other members:

People who have knowledge or skills that will be helpful for
completing the project:

Success Factors

What leadership and
resources are needed to
make this improvement a
success?

•
•
•
•

Source: Adapted from Rohe and Spath (2005). Used with permission.

EXHIBIT 12.1
Improvement
Project Charter
Template

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Applying Qual i ty Management in Healthcare: A Systems Approach232

Once the initial project charter is drafted, its completeness can be
evaluated using the following criteria:

• It specifies, in detail, the performance problem to be addressed.
• It contains measurable objectives that include target goals to be

achieved.
• It sets realistic deadlines and expectations.
• It contains defined time lines for completion of the project.
• It is relevant to the organization’s strategic quality goals.

If revisions are needed in the charter, the team should make them before
the start of the project. Otherwise, the lack of clarity can eventually derail the
improvement effort.

Performance Improvement Teams

Improvement methodologies such as Plan, Do, Check, Act and Six Sigma
serve as critical thinking frameworks for managers studying any problems that
may arise. Project teams also use these methodologies as they work to improve
performance in a particular functional area. Regardless of the model used for an
improvement project, assembling a team of people personally knowledgeable
about the process to be improved is essential. Composition of the team (the
number and identity of the members) and meeting frequency and duration
are guided by the process purpose and scope. The questions that influence
makeup of the team should include the following:

• What knowledge is required to understand the process and design the
actual improvement intervention(s)?

• How should the team be designed to support the processes needed to
accomplish implementation within the project constraints?

The number of team members needed to successfully achieve the project
objective will vary. Managers need to take into account the number of staff
members that can be taken away from their usual work without adversely
affecting services. The optimal size of a team is between five and eight
individuals. However, the size of the team is not as important as the diversity
of its members. The team should include people who have different roles and
perspectives on the process to be improved (Agency for Healthcare Research
and Quality 2013). Individual contributions during a meeting tend to diminish
as the size of the group grows beyond six members.

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Chapter 12: Using Improvement Teams and Tools 233

Just as managers use human resources practices that promote matching
an employee’s traits with the requirements of the job, managers may also match
employees with the various roles and stages required in a change or improvement
process. Problems in group processes tend to arise from a mismatch between
a project stage and an individual rather than from problems inherent in the
individuals themselves. Intentionally engaging individuals at the appropriate
time, as well as offering support or requesting patience during other times, can
enhance the effectiveness of both the team and the manager.

For instance, a team member favoring concrete thinking may get
frustrated with creating a vision, though he will be essential in determining
the logistics of implementing process changes. Someone with well-developed
interpersonal or relational skills can be on the alert for any staff morale issues
related to the changes. An employee who is good at seeing the big picture will
be invaluable in identifying unintended consequences. A team member who
is detail oriented can be an ideal choice for monitoring progress and ensuring
follow-through; another member who is action oriented can make sure the
project moves along on schedule.

Meeting Schedules and Frequency
Typically, team meetings are held weekly, biweekly, or monthly, and they
generally last one to two hours. Some of the challenges associated with this
approach in health services organizations include the time-consuming patient
care duties required of clinical providers, the late arrival of team members
because of other competing responsibilities, the need to devote portions
of the meeting to updating team members, and dwindling interest as the
project drags on.

Consider an alternative approach. If managers use a systematic method
for approaching improvements, they will begin to get a sense for the total
team time required for an improvement effort. For example, a team may take
about 40 hours to complete the various phases of an improvement project.
If the improvement effort is constrained by time or dollars, the team is faced
with increasing its own productivity or reducing its own cycle time. With this
limitation in mind, the 40 hours of time may be distributed in a variety of ways
other than in one-to-two-hour segments. For example, ten four-hour meetings
or five eight-hour meetings may better meet the needs of a particular project
team. The meetings may occur once a week for ten weeks, twice a week for five
weeks, or every day for one week. Based on the work environment, a strategy
may be selected that balances project team productivity, daily operational
capacity and requirements, the scope of the desired improvement, and project
deadlines.

A concentrated team meeting schedule has several advantages:

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Applying Qual i ty Management in Healthcare: A Systems Approach23

• It demonstrates the organization’s or management’s commitment to
change.

• It saves duplication and repeated work associated with bringing
everyone up to speed at each meeting.

• It establishes traction by contributing to the elements of creative
tension.

• It reduces the cycle time from concept to implementation.
• It forces managers and teams out of the “firefighting” mentality into

one of purposely fixing not just the symptoms of problems but also the
underlying problems themselves.

Decision Making
Consensus is a commonly employed approach to decision making in which the
team seeks to find a proposal acceptable enough that all members can support
it (Scholtes, Joiner, and Streibel 2003). Seeking consensus may, however,
reduce decisions to the lowest common denominator (Lencioni 2002). In a
team comprising primarily concrete, practical, linearly thinking members, how
likely is it that an idea posed by the one creative, conceptual team member will
gain enough acceptance to be considered a possible solution to a problem?
Conversely, on a team of creative, conceptual innovators who are quickly
moving forward on an idea without regard for the practical considerations of
implementation, how likely will it be that they embrace the input from the one
concrete, practical, linearly thinking team member? In either case, the result will
be less than optimal. The best result (i.e., improvement intervention) in these
two circumstances may come from listening to the “outlier”; perhaps that team
member’s perspective best matches the requirements of the decision at hand.

Using decision criteria is an alternative to consensus. For example, in
one improvement effort, the criteria for pursuing an improvement idea include
the following (Kelly 1998):

• Does it fit within the goal of the effort?
• Does it meet customer requirements?
• Does it meet regulatory or accreditation requirements?
• Does it remain consistent with the department’s or organization’s

purpose?
• Does it support the vision?
• Does it demonstrate consistency with quality principles?

In this case, team members are expected to question and challenge each
improvement idea. Those that meet the criteria are further evaluated by the
team. All team members may not completely understand an idea the first time

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Chapter 12: Using Improvement Teams and Tools 235

it is discussed, but the team can save time by quickly discarding ideas that do
not meet criteria. Instead, they can then spend time on understanding and
evaluating ideas that do meet criteria.

Managers can help support team decision making by staying informed
about the progress of improvement projects. They can best keep up with events
through periodic meetings with the team leaders. Unexpected “drop ins”
by team managers in search of project updates can be disruptive to the team
process. Some types of questions a project team leader would find helpful to
discuss face-to-face with the manager or managers affected by the improvement
project are listed in exhibit 12.2. These questions are especially useful during
the action-planning stage of a project, when they can provide the team leader
with a better understanding of leadership support, communication needs, and
direction.

Improvement Tools and Techniques

In most improvement projects, regardless of the methodology followed,
similar process improvement tools and techniques are used for understanding
the performance problem and how to correct it. Appendix 12.1 provides
descriptions of many frequently used tools and techniques. Some items in the
list are described in greater detail in this chapter or covered in chapter 10.

• Does the manager have any preset expectations about what needs to be
done to improve performance? Is the manager open to accepting the team’s
recommendations, or does she have alternatives?

• Are the desired time frames for completing the improvement interventions
realistic? Can the manager support these time frames?

• What resources (dollars, time, etc.) can be spent on the improvement
interventions? What are the resource limitations?

• Is the manager willing to tolerate possible dips in productivity or service while
the process changes are being implemented?

• Will the manager help prepare people to minimize disruptions during the
implementation of improvement plans?

• What will make the manager anxious during the intervention design and
implementation phase? How soon does he expect to see positive changes?

• If an individual or group resists making the needed changes, will the manager
be willing to initiate appropriate pressure to correct the problem?

• Will the manager help dismantle the “old way” of doing things by holding
fast to and reinforcing the redesigned way until it has had time to prove its
effectiveness?

EXHIBIT 12.2
Project Team
Leader and
Manager
Discussion
Questions

Source: Adapted from Rohe and Spath (2005). Used with permission.

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Applying Qual i ty Management in Healthcare: A Systems Approach236

Readers are encouraged to learn more about tools not explained in depth here
by using the resources found at the end of this chapter.

Document the Process
Some of the most valuable improvement tools are those that help managers
and teams better understand work processes. Often, a process is followed
because “that’s how we’ve always done it” or because a certain way of doing
things has simply evolved over time. Before a process can be improved, it must
be understood. The tools described in this section help managers and teams
understand processes by documenting the steps involved.

According to the American Society for Quality (ASQ), a process is “an
organized group of related activities that work together to transform one or
more kinds of input into outputs that are of value to the customer” (ASQ
2016a). This definition suggests the following key features of a process (ASQ
2016a; italics added):

• A process is a group of activities, not just one.
• The activities that make up a process are not random or ad hoc; they are

related and organized.
• All the activities in a process must work together toward a common goal.
• Processes exist to create results your customers care about.

A process flowchart is a graphical representation of the steps
in a process or project. Types of activities in the process are represented
by variously shaped symbols. An oval indicates the start and end of the
process, a rectangle indicates a process action step, and a diamond indicates
a decision that must be made in the process. Depending on the decision,
the process follows different paths. A simple process flowchart is illustrated
in exhibit 12.3. Clinical providers may already be familiar with this tool, as
many clinical algorithms and guidelines are communicated using process
flowcharts. Professionals from other specialties, such as laboratory, radiology,
and information systems, may also be familiar with this tool, as more complex
versions of a process flowchart are used to document technical standard
operating procedures or data and information flow.

At times, many individuals, departments, or organizations are involved
in carrying out different steps of a single process. In such cases, a deployment
flowchart (vertical flowchart) or “swim lanes” chart (horizontal flowchart)
is used to indicate who is responsible for which steps of the process. Efforts
to improve coordination of process steps may be enhanced by identifying,
documenting, and understanding the essential handoffs that occur in a process.

process
“an organized
group of related
activities that
work together
to transform one
or more kinds of
input into outputs
that are of value
to the customer”
(ASQ 2016a)

process flowchart
graphical
representation
of the steps in a
process or project

deployment
flowchart
process flowchart
diagram that
indicates who is
responsible for
which steps of the
process

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Chapter 12: Using Improvement Teams and Tools 237

Exhibit 12.4 shows simple deployment flowcharts illustrating coordination
between an orthodontist and an oral surgeon in providing care for a teenage
patient.

Using a flowchart to document a process allows managers and teams to
see a picture of the process. Often, just seeing a picture leads to obvious ideas
for improvement. Additional benefits include the opportunity to distinguish
the distinct steps involved; identify unnecessary steps; understand vulnerabilities
where breakdowns, mistakes, or delays are likely to occur; detect rework loops
that contribute to inefficiency and quality waste; and define who carries out
which step and when. The process of discussing, reviewing, and documenting
a process using a flowchart provides the opportunity for clarifying operating
assumptions, identifying variation in practice, and establishing agreement on
how work should be done.

Uncover Improvement Opportunities
A cause-and-effect diagram is a tool for organizing and documenting, in
a structured format, the causes of a problem (Scholtes, Joiner, and Streibel
2003). The diagram may capture actual (observed) causes and possible (from
brainstorming) causes. Kaoru Ishikawa, a Japanese quality management specialist,
originally created this tool for use in product design and defect prevention.

cause-and-
effect diagram
(or fishbone or
Ishikawa diagram)
tool for organizing
and documenting,
in a structured
format, the causes
of a problem

Time to
get up

Alarm
goes off

Too
tired?

Wake up

Get out
of bed

Start and
end of
process

Action
step

Decision
step

Hit snooze
button

Yes

Connects process steps

EXHIBIT 12.3
Simple Process
Flowchart

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Applying Qual i ty Management in Healthcare: A Systems Approach238

Because this diagram resembles a fish (the head represents the problem
and the bones represent the causes), it is also referred to as a fishbone diagram
(see exhibit 12.5). The problem is written on the far right of the diagram.
Categories of causes are represented by the diagonal lines (bones) connected
to the horizontal line (spine), which leads to the problem (head). The bones
of the fish may be labeled in a variety of ways to represent categories of causes,
including people, plant and equipment, policies, procedures, manpower,
methods, and materials. Exhibit 12.6 is an example of a fishbone diagram.

Identify
need for

oral

surgery

Orthodontist

Make
referral

Assess
patient and
plan surgery

Perform
surgical

procedure

Continue
orthodontia

treatment

Procedure
summary to
orthodontist

Orthodontist

Oral Surgeon

Identify
need for oral

surgery

Make
referral

Continue
orthodontia
treatment

Assess
patient and
plan surgery

Perform
surgical

procedure

Procedure
summary to
orthodontist

Oral SurgeonVertical
Flowchart

Horizontal Flowchart

EXHIBIT 12.4
Simple

Deployment
Flowcharts

EXHIBIT 12.5
How the

Fishbone
Diagram Got Its

Name

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Chapter 12: Using Improvement Teams and Tools 239

In exhibit 12.6, the problem is stated at the head of the fish (low
hand-hygiene compliance) and the categories of causes are labeled as policies,
procedure, people, and plant/equipment. Detailed causes are identified and
represented by the small bones of the fish shown in the people category.

Stating the problem is the most important step in creating the fishbone
diagram. Problem statements that are too narrow, vague, or poorly constructed
can limit this tool’s effectiveness in the improvement process. Users may be
tempted to begin generating solutions (rather than documenting causes)
in a fishbone diagram. However, users should take care to focus on cause,
because identifying solutions too soon also limits the tool’s usefulness and the
opportunity to further investigate the problem.

A causal loop diagram is used to display the dynamic between cause and
effect from a relational standpoint. While cause-and-effect diagrams elicit the
categories of causes that affect a problem, causal loops show the interrelation
between causes and their effects. When finished, a causal loop diagram provides
an understanding of the positive and negative reinforcements that describe the
system of behavior.

Exhibit 12.7 shows a simple causal loop diagram, including a problem
statement: Maintaining qualified operating room (OR) staff during the nursing
shortage is getting difficult. The causal loop diagram illustrates the behaviors
that affect system outcomes. The cause-to-effect relationship is determined to
be reinforcing (+) or negative (−). These designations do not indicate that the
relationship is good or bad. They just mean that as the cause intensifies, effects
do too, and as the cause diminishes, the effect does also.

An advantage of causal loops is that they depersonalize the process.
People can point at the arrows in the loop that are reinforcing the problem

causal loop
diagram
visual representa-
tion that displays
the dynamic
between cause and
effect from a rela-
tional standpoint

Policies Plant/Equipment

Procedures People

Statement of
Problem:
Low hand-hygiene
compliance

Policy is outdated
Not enough hand sanitizer
dispensers in patient care areas

Sinks not conveniently located

Staff perceive they
are doing a good job alreadyInadequate resources to monitor

hand-washing technique

Too busy
Lack of
feedback

Not a management
priority

Lack of knowledge

Poor attendance at
training sessions

EXHIBIT 12.6
Fishbone

Diagram

Example

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Applying Qual i ty Management in Healthcare: A Systems Approach2

instead of pointing at people. The causal loop diagram illustrates the behaviors
that affect system outcomes.

Not all identified causes influence the problem equally. Data about how
important causes are or how often causes occur aid managers in prioritizing
and selecting improvement interventions. A Pareto chart is a helpful tool in
this process. In appearance, it is like a histogram, but with the data sorted in
order of decreasing frequency of events; it also includes other annotations to
highlight the Pareto principle. The Pareto chart is named after nineteenth-
century economist Vilfredo Pareto and refers to the Pareto principle, which
suggests “most effects come from relatively few causes; that is, 80 percent of
the effects come from 20 percent of the possible causes” (ASQ 2016b).

Exhibit 12.8 is an example of a Pareto chart based on data collected
about the causes in exhibit 12.6. Prior to collecting and displaying the data,
a nursing manager plans an educational session (e.g., how to wash hands).
However, after systematically analyzing the problem, the manager realizes that
the cause is the availability of supplies. He installs more hand sanitizer dispensers
and provides small bottles for staff to carry in their pockets.

Select Improvement Actions
Once the causes of a problem are understood and opportunities for improvement
are clearly identified, actions intended to resolve the problems are selected.
A team may have several ideas of what actions must be taken. However, a
decision matrix that “evaluates and prioritizes a list of options” (ASQ 2016c)
is an improvement tool that can help the team gain consensus.

To use a decision matrix, sometimes called a prioritization matrix, the
team first comes up with criteria for judging the proposed actions (e.g., easy

Pareto chart
image similar to
a histogram, but
with the data
sorted in order
of decreasing
frequency of
events and with
other annotations
to highlight the
Pareto principle

Pareto principle
theory that “most
effects come from
relatively few
causes; that is,
80 percent of the
effects come from
20 percent of the
possible causes”
(ASQ 2016b)

decision matrix
improvement tool
that “evaluates
and prioritizes a
list of options”
(ASQ 2016c)

Maintaining Qualified OR Staff
During Nursing Shortage Is

Getting Difficult

+
+

+ +

Overtime is
incurred

Staff burn out Staff are
discontented

Staff leave

Temps get
preferential treatment

Temps take time from
staff to train to be

productive

Bring in
temporary staff

Workload is greater
than staff can

complete

EXHIBIT 12.7
Causal Loop

Diagram
Example

Source: Adapted from Rohe and Spath (2005). Used with permission.

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Chapter 12: Using Improvement Teams and Tools 241

or hard to implement, low or high cost, low or high impact). The members
then judge actions against the goal of the project using these criteria and
a numeric rating system. For instance, if the goal of a nursing care center’s
improvement project is to reduce resident falls by 20 percent, the criteria
are applied individually by team members to each action being considered.
An example of a simple decision matrix for the patient fall reduction project
is illustrated in exhibit 12.9. Actions receiving higher scores are considered
the best to implement. The team may ultimately implement all the actions
being proposed, using the decision matrix to prioritize which actions to
implement first.

If the criteria are not deemed by the team to be of equal importance,
various statistical methods can be used to numerically weight each criterion
(Minnesota Department of Health [MDH] 2016). For instance, “ease of
implementation” may have a weight of 0.50, while “impact” might have a
weight of 0.80.

An issue may come up during the action planning phase of an
improvement project that relates to the expected success of the intervention.
Force field analysis is “a technique for evaluating all the various forces for and
against a proposed change” (McLaughlin and Olson 2012, 160). This technique
can help the team determine whether a planned intervention can be successfully
implemented. If the team has already chosen a particular intervention, a force
field analysis can help in developing strategies for overcoming barriers to success.

Shown in exhibit 12.10 is a force field analysis developed by a hospital
team involved in a project aimed at improving patient-centered care. The
team had decided that moving the location of shift handoffs from the nurses’
station to the patient’s bedside would allow patients to be more involved in
their care. The restraining forces were found to be significant; however, the
team still chose to make this change. By using a force field analysis to identify

force field analysis
“a technique for
evaluating all of
the various forces
for and against a
proposed change”
(McLaughlin and
Olson 2012, 160)

140

100

Not enough
hand rub

Sinks not
convenient

Staff
perception

Too busy Lack of
knowledge

Inadequate
resources

Outdated
policy

Number of observations Cumulative percentage

100
90

N
o.

o
f O

bs
er

va
ti

on
s

%
of Total O

bservations
.

. .

EXHIBIT 12.8
Pareto Chart
Example

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Applying Qual i ty Management in Healthcare: A Systems Approach242

Project Goal: Reduce resident falls by 20 percent in one year.

Proposed Action
Ease of

Implementation Cost Impact Total

Hard = 1 →
Easy = 5

High = 1 →
Low = 5

Low = 1 →
High = 5

“Ask for Help” signs in
resident rooms

5 5 1 11

Bed alarms for high fall-
risk residents

3 1 4 8

Change floor wax to a slip-
resistant product

5 5 3 13

Add check that mobility
devices are in the
residents’ reach to hourly
resident rounds

5 5 3 13

EXHIBIT 12.9
Decision Matrix

Example

secroF gniniartseRsecroF gnivir

Plan:
Change to

bedside shift
handover

Critical incidents
on the increase

Staff knowledgeable in
change management

Increase in discharge
against medical advice

Complaints from patients
and doctors increasing

Care given is predominantly
biomedical in orientation

Ritualism and
tradition

Fear that this may
lead to more work

Fear of increased
accountability

Problems associated
with late arrivals

Possible disclosure of
confidential information

EXHIBIT 12.10
Force Field

Analysis
Example

Source: Adapted from McLaughlin and Olson (2012). Used with permission.

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Chapter 12: Using Improvement Teams and Tools 243

the restraining forces prior to implementation, the team could then design the
action plan in a way that would minimize these forces.

Monitor Progress and Hold the Gains
Following an improvement project, there must be a control system that
allows management to measure progress toward goal attainment and identify
unacceptable variances requiring action. One of the hallmarks of a good control
system is that corrective action is taken as soon as it is found to be needed.
Why wait until the end of the year to discover that an improvement project has
not changed performance as expected? However, at the other end of the scale,
should a manager check performance every week? That may make no sense,
either. Monthly checking is probably about right unless the organization’s
leaders or healthcare regulators want more frequent checks.

A commonly used tool to monitor performance following an
improvement project is a run chart, a graphic representation of data over time.
This chart is described in chapter 10 and also discussed here because of its
importance in monitoring the results of improvement projects. Run charts are
useful for tracking progress after an improvement intervention and monitoring
the performance of ongoing operations. On a run chart, the x axis represents
the time interval (e.g., day, month, quarter, year) and the y axis represents the
variable or attribute of interest. Displaying data on a run chart also enables
a manager to more readily detect patterns or unusual occurrences in the data.
Exhibit 12.11 shows a run chart tracking patient complaints about hospital
noise at night. An intervention that involved some environmental changes—
action that was taken as a result of an improvement project—is indicated with
the arrow.

While managers should monitor performance following individual
interventions, such as creating a quieter nighttime environment for hospitalized
patients, changing system behavior often requires more than one intervention.
Numerous factors contribute to consistent and successful practice, as illustrated
in the simple cause-and-effect diagram in exhibit 12.6. Eliminating one of these
causes can increase compliance a little; however, a problem with multiple causes
requires a multifaceted improvement plan. For example, the World Health
Organization (WHO) endorses a combination of interventions (exhibit 12.12)
to improve the hand-hygiene compliance of health services workers.

Implementing the WHO guidelines involves improving multiple
processes and engaging multiple stakeholders and departments throughout
an organization on a continual basis.

Exhibit 12.13 provides an example of a control chart (sometimes
called a process behavior chart). This graph provides a moving picture of the
variation of key performance parameters. The control chart illustrates one
organization’s experience with continuous attention to and improvement of its

variable
number that
“take[s] on
different values
on a continuous
scale” (Carey and
Lloyd 2001, 70)

attribute
tally of “events that
can be aggregated
into discrete
categories” (Carey
and Lloyd 2001, 70)

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Applying Qual i ty Management in Healthcare: A Systems Approach244

N
um

be
r

of
C

om
pl

ai
nt

Month

Changes Made in Environment

Average

J F M A M J J A S O N D

10
8 9

6
7

EXHIBIT 12.11
Run Chart of

Monthly Patient
Complaints

About Hospital
Noise at Night

Source: McLaughlin and Olson (2012). Used with permission.

System Change: ensuring that the necessary infrastructure is in place to allow
healthcare workers to practice hand hygiene.

Training/Education: providing regular training on the importance of hand
hygiene, based on the “My 5 Moments for Hand Hygiene” approach, and the
correct procedures for hand rubbing and hand washing, to all healthcare workers.

Evaluation and Feedback: monitoring hand-hygiene practices and infrastructure,
along with related perceptions and knowledge among healthcare workers, while
providing performance and results feedback to staff.

Reminders in the Workplace: prompting and reminding healthcare workers
about the importance of hand hygiene and about the appropriate indications and
procedures for performing it.

Institutional Safety Climate: creating an environment and the perceptions that
facilitate awareness-raising about patient safety issues while guaranteeing
consideration of hand hygiene improvement as a high priority at all levels.

EXHIBIT 12.12
WHO Hand-

Hygiene
Recommendations

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Chapter 12: Using Improvement Teams and Tools 245

multifaceted hand-hygiene initiative. System behavior, as measured by hand-
hygiene compliance rates, has been tracked each month for a three-year period.
As various interventions were implemented, the graph allowed managers to
see how the interventions affected system performance. Over the three-year
period, one sees an improvement of the average compliance rate per year and a
narrowing of the range, indicating more predictable and dependable behavior
in the direction of 100 percent compliance.

If an improvement project fails to achieve desired results and the
performance issue continues to be of strategic importance to the organization,
another project should be initiated with the same or different team members.
The first step for this team should be to conduct a postmortem on the failed
project to determine what went wrong so the repeat project will not fall into
the same traps. A survey of 167 frontline leaders from four Midwest community
hospitals found the top reasons improvement projects are not successful
(Longenecker and Longenecker 2014, 150):

1. Poor implementation planning and overly aggressive time lines
2. Failure to create buy-in or ownership of the initiative
3. Ineffective leadership and lack of trust in upper management
4. Failure to create a realistic plan or improvement process
5. Ineffective, unilateral communications
6. A weak case for change, unclear focus, and unclear desired outcomes
7. Little or no teamwork or cooperation

UCL

Avg

LCL

100
90

Monthly observed compliance
Upper control limit (UCL)
(Avg + 3 St Dev)

Yearly average
Lower control limit (LCL)
(Ave – 3 St Dev)

ra
M

rp
A

ya
M

nuJ
uJ

l gu
A

peS
t

c
O

t o
N

v ce
D

naJ eF
b a

M
r p

A
r ya

M
nuJ
uJ

l gu
A

peS
t

c
O

t o
N

v ce
D

naJ eF
b ra

M
p

A
r ya

M
nuJ
luJ gu

A
peS

t
c

O
t o

N
v ce

Year 1 Year 2

P
er

ce
nt

ag
e

Co
m

pl
ia

nc
e

Year 3

EXHIBIT 12.13
Three-Year
Hand-Hygiene
Compliance
Rates

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Applying Qual i ty Management in Healthcare: A Systems Approach246

8. Failure to provide ongoing measurement, feedback, and accountability
9. Unclear roles, goals, and performance expectations

10. Lack of time, resources, and support from upper management

Summary

Quality management is most successful when it is a bottom-up, team activity.
The people personally involved in the process to be improved are best suited
to identify the causes of performance problems and to propose and implement
solutions. Involving frontline staff in improvement projects also reduces
resistance to change. This chapter describes the role of managers throughout
the life of an improvement project—from chartering the team to selecting the
improvement strategies to monitoring the results.

Improvement tools and techniques are used during various steps of an
improvement project. There are many different tools and techniques that can
be used to document the process, uncover improvement opportunities, select
improvement actions, monitor progress, and hold the gains. This chapter covers
several of these tools and techniques, and students are encouraged to use the
companion readings and web resources provided to learn more.

Exercise 12.1
Objective: To practice creating a project charter.

Instructions: Read the case study. Assume you are one of the two directors
in the case study, and you are writing a team charter jointly with the other
director to address the problems identified in the case study. Use the template
in exhibit 12.1 or a similar format to document the project charter.

Case Study: The directors of imaging services and surgical services in a hospital
are discussing an improvement opportunity involving care provided to patients
with breast cancer. The hospital is encountering delays for procedures involving
surgical removal of breast tissue (lumpectomy) in the area where an image-
guided core needle biopsy has been performed. During the surgery, the removed
tissue is imaged to ensure that the biopsy clip and microcalcifications are present
in the specimen. The imaging must be done with a mammographic unit to
provide visualization of the microcalcifications. Because the mammography
machines are in the Breast Center, which is only open regular business hours,
scheduling for the lumpectomy procedures is restricted to when a mammography
technologist is available. This limitation causes delays as late as 8:00 pm, and
technologists must be paid overtime for these evening procedures. In addition,
even during Breast Center operating hours, the breast tissue has to be packaged

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Chapter 12: Using Improvement Teams and Tools 247

and delivered by hand from the operating suite to the imaging department—
and after the specimen is imaged, it must be returned to surgery, all while the
surgeon waits with the patient still under general anesthesia. The hospital is not
able to meet the needs of the surgeon for late cases, and even the requirements
for cases during the day are not being fully met.

Exercise 12.2
Objective: To practice creating a process flowchart.

Instructions: Develop a flowchart for a healthcare process that you are familiar
with. The flowchart should have a starting point and an end point. All key
process steps should be included. Use the type of flowchart that will best display
the steps in your chosen process. The flowchart can be hand drawn, or you can
use software such as Microsoft Excel, Visio, or PowerPoint. Two examples of
flowcharts are provided in this chapter, and the web resources included at the
end of this chapter contain additional examples.

Companion Readings

Agency for Healthcare Research and Quality. 2013. Practice Facilitation Handbook.
Published June. www.ahrq.gov/professionals/prevention-chronic-care/
improve/system/pfhandbook/index.html.

Harel, Z., S. A. Silver, R. F. McQuillan, A. V. Weizman, A. Thomas, G. M. Chertow,
G. Nesrallah, C. T. Chan, and C. M. Bell. 2016. “How to Diagnose Solutions
to a Quality of Care Problem.” Clinical Journal of the American Society of
Nephrology 11 (5): 901–7.

Health Resources and Services Administration. 2016. “Improvement Teams.”
Accessed November 16. www.hrsa.gov/quality/toolbox/methodology/
improvementteams/index.html.

Lenderman, H., H. Reffett, J. Moran, and M. Beaudry. 2014. “Selecting Quality
Improvement Team Members.” Public Health Foundation. Published May 19.
www.phf.org/resourcestools/Documents/Team_Member_Selection_Tool .

McQuillan, R. F., S. A. Silver, Z. Harel, A. V. Weizman, A. Thomas, C. M. Bell, G.
M. Chertow, C. T. Chan, and G. Nesrallah. 2016. “How to Measure and
Interpret Quality Improvement Data.” Clinical Journal of the American Society
of Nephrology 11 (5): 908–14.

Minnesota Department of Health. 2016. “Public Health and Quality Improvement
Resources and Tools.” Accessed November 16. www.health.state.mn.us/divs/
opi/qi/toolbox.

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Applying Qual i ty Management in Healthcare: A Systems Approach248

Public Health Foundation. 2011. Applications and Tools for Creating Healthy Teams.
Published April. www.phf.org/resourcestools/Documents/Applications_and_
Tools_for_Creating_and_Sustaining_Healthy_Teams .

Silver, S. A., Z. Harel, R. McQuillan, A. V. Weizman, A. Thomas, G. M. Chertow,
G. Nesrallah, C. M. Bell, and C. T. Chan. 2016. “How to Begin a Quality
Improvement Project.” Clinical Journal of the American Society of Nephrology
11 (5): 893–900.

Silver, S. A., R. McQuillan, Z. Harel, A. V. Weizman, A. Thomas, G. Nesrallah, C.
M. Bell, C. T. Chan, and G. M. Chertow. 2016. “How to Sustain Change and
Support Continuous Quality Improvement.” Clinical Journal of the American
Society of Nephrology 11 (5): 916–24.

Weston, M., and D. Roberts. 2013. “The Influence of Quality Improvement Efforts
on Patient Outcomes and Nursing Work: A Perspective from Chief Nursing
Officers at Three Large Health Systems.” OJIN: The Online Journal of Issues
in Nursing 18 (3). Published September. www.nursingworld.org/Quality-
Improvement-on-Patient-Outcomes.html.

Web Resources

Agency for Healthcare Research and Quality flowcharts: https://healthit
.ahrq.gov/health-it-tools-and-resources/workflow-assessment-
health-it-toolkit/all-workflow-tools/flowchart

Institute for Healthcare Improvement: www.ihi.org

References

Agency for Healthcare Research and Quality. 2013. “Module 14: Creating Quality
Improvement Teams and QI Plans.” Reviewed May. www.ahrq.gov/
professionals/prevention-chronic-care/improve/system/pfhandbook/mod14.
html.

American Society for Quality (ASQ). 2016a. “Decision Matrix.” Accessed July 15.
http://asq.org/learn-about-quality/decision-making-tools/overview/
decision-matrix.html.

———. 2016b. “Glossary—P.” Accessed July 15. http://asq.org/glossary/p.html.
———. 2016c. “Process View of Work.” Accessed July 15. http://asq.org/

learn-about-quality/process-view-of-work/overview/overview.html.
Carey, R. G., and R. C. Lloyd. 2001. Measuring Quality Improvement in Healthcare: A

Guide to Statistical Process Control Applications. Milwaukee, WI: Quality Press.

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Chapter 12: Using Improvement Teams and Tools 249

Kelly, D. 1998. “Reframing Beliefs About Work and Change Processes in Redesigning
Laboratory Services.” The Joint Commission Journal on Quality Improvement
24 (9): 154–67.

Lencioni, P. 2002. The Five Dysfunctions of a Team: A Leadership Fable. San Francisco:
Jossey-Bass.

Longenecker, C. O., and P. D. Longenecker. 2014. “Why Hospital Improvement
Efforts Fail: A View from the Front Line.” Journal of Healthcare Management
59 (2): 147–57.

McLaughlin, D. B., and J. R. Olson. 2012. Healthcare Operations Management, 2nd
ed. Chicago: Health Administration Press.

Minnesota Department of Health (MDH). 2016. “Public Health and QI Tool Box:
Prioritization Matrix.” Accessed July 15. www.health.state.mn.us/divs/opi/
qi/toolbox/prioritizationmatrix.html.

Rohe, D., and P. L. Spath. 2005. 101 Tools for Improving Health Care Performance.
Forest Grove, OR: Brown-Spath & Associates.

Scholtes, P. R., B. L. Joiner, and B. J. Streibel. 2003. The Team Handbook, 3rd ed.
Madison, WI: Oriel.

Shiba, S., and D. Walden. 2002. “Quality Process Improvement Tools and Techniques.”
Massachusetts Institute of Technology and Center for Quality of Management.
Published July 30. www.walden-family.com/public/iaq-paper .

UK Department of Trade and Industry. 2016. “Tools and Techniques for Process
Improvement.” Accessed July 15. www.businessballs.com/dtiresources/TQM_
process_improvement_tools .

World Health Organization (WHO). 2009. A Guide to the Implementation of the WHO
Multimodal Hand Hygiene Improvement Strategy. Accessed July 15, 2016.
www.who.int/gpsc/5may/Guide_to_Implementation .

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Applying Qual i ty Management in Healthcare: A Systems Approach250

Appendix 12.1

Frequently Used Improvement Tools

Tool Name Description

Affinity diagram Visualization that organizes ideas and issues
to help in understanding the essence of a
situation and possible actions

Arrow diagram Graphical representation showing the network
of tasks and milestones required to implement
a project

Bar chart (or bar graph) Display of data in which the height of the bars
is used to show the relative size of the quantity
measured

Benchmarking Comparison of a process with a “best practice”
or “best in class” to learn how to improve that
process

Brainstorming Process that allows a team to creatively
generate ideas about a topic in a “judgment-
free zone”

Capability measures Various measures of the natural variation of
process outputs (e.g., a limit of three standard
deviations on a control chart) and specification
limits (e.g., six sigma)

Causal loop diagram Advanced type of relations diagram

Cause-and-effect diagram
(or fishbone diagram or
Ishikawa diagram)

Visualization that organizes and documents
causes of a problem in a structured format

Check sheet (or tally sheet) Form used to record and compile data from
archives or observations to detect trends or
patterns

Control chart Display of data quantifying variation to monitor
whether a process is continuing to operate
reliably; also used to detect the effect of a
process change

Decision matrix Diagram used to evaluate and prioritize a list of
options

(continued)

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Chapter 12: Using Improvement Teams and Tools 251

Tool Name Description

Design of experiments Systematic method that determines the
relationship between factors affecting a
process and the output of that process

Dot plot (or tally chart) Visualization showing how often a particular
value has occurred (frequency), with the shape
of the plot giving a picture of the variation and
highlighting unusual values

5S methodology Philosophy and a five-step way of organizing
and managing the workspace by eliminating
waste

Five Whys Process in which, when a problem occurs, its
nature and source are discovered by asking
“Why?” several times

Force field analysis Examination that identifies forces that help or
hinder change or improvement

Graphs and graphical
methods

Many different techniques for showing data
visually and analyzing the data

Histogram Display showing the centering, dispersion, and
shape of the distribution of a collection of data

Matrix diagram Visualization showing multidimensional
relationships

Pareto chart (or analysis
diagram)

Visual representation similar to a histogram
but with the data sorted in order of decreasing
frequency of events and with other annotations
to highlight the Pareto effect (i.e., the 20
percent of situations that account for 80
percent of results)

Poka-yoke (or
mistake-proofing)

Methods for preventing mistakes

Process flowchart Graphical representation of the steps in a
process or project

Queuing theory Analysis of delays and wait times

Regression analysis Analysis of the relationship between response
(dependent) variables and influencing factors
(independent variables)

Relations diagram Visualization showing a network of cause-and-
effect relationships

Run chart (or line graph) Graphical representation of data over time

(continued)

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Applying Qual i ty Management in Healthcare: A Systems Approach252

Tool Name Description

Sampling Statistical tool that selects a few instances from
a set of events, from which characteristics of
the entire set are inferred

Scatter diagram (or plot) Graphical method of showing correlation
between two variables

Stratification of data Classification of data from multiple categories,
such as what, where, when, and who

Tree diagram Visualization that organizes a list of events or
tasks into a hierarchy

Value-stream mapping Graphical representation of the process of
services or product delivery with use of inputs,
throughputs, and outputs

Sources: Adapted from MDH (2016); Shiba and Walden (2002); UK Department
of Trade and Industry (2016).

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301301

PRACTICE EXERCISE 7: IMPROVING
A PERFORMANCE GAP IN YOUR
ORGANIZATION

Objectives

• To provide an opportunity for managers to be involved in a
performance improvement effort using the actual identified needs in
their own organizations

• To practice improvement approaches in a safe and controlled setting.

Note: Implementing the results of this exercise in your own organization
is not required. However, the exercise requires you to think through and
document all of the steps in the exercise as if you were actually conducting
this effort in your organization.

Instructions

1. Describe one of the performance gaps you identified in Exercise 6:
Organizational Self-Assessment or a performance gap that you are aware
of in the scope of your defined work unit or responsibilities.

2. Briefly describe the process(es) or function(s) that makes up this
performance area.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
Created from franklin-ebooks on 2023-02-08 00:21:55.

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Applying Qual i ty Management in Healthcare: A Systems Approach302302

3. List whom you would invite to participate in your improvement effort
and why you selected them.

4. a. State and critique several possible goal statements for this
improvement effort. Use the following Goals Worksheet to organize
your thinking.

b. Based on your critique, select the goal you will use for the
improvement effort.

Goals Worksheet

Goal Statement Type of Goal Pros Cons

5. Practice the purpose principle (chapter 6) by asking yourself the
following questions:
– What am I trying to accomplish?

– What is the purpose of the process(es) identified in question 2?

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
Created from franklin-ebooks on 2023-02-08 00:21:55.

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303Pract ice Lab 303

– Have I further expanded the purpose? What is the purpose of my
previous response?

– Have I further expanded the purpose? What is the purpose of my
previous response? (Continue expanding the purpose, if needed.)

– What larger purpose may eliminate the need to achieve this smaller
purpose altogether?

– What is the right purpose for me to be working on? (Describe how
this purpose differs or does not differ from the original purpose.)

6. Review your selected goal from question 4. After completing the
purpose questions in question 5, does this goal still seem appropriate? If
not, redefine the goal of your improvement effort.

7. Is the process (or processes) from question 2 still the appropriate
process to improve? If not, describe the process(es) you will improve.

8. Describe the customers of the process and their expectations or
requirements.

9. Describe a performance measure for this process, how the data are
collected, and a graph that could be used to display the measurement
results. This performance indicator may be the original from which you
determined this performance gap.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
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Applying Qual i ty Management in Healthcare: A Systems Approach304304

10. Document the process steps as they are currently carried out using a
high-level flowchart.

11. Practice identifying mental models (chapter 8):
– Identify at least two mental models that may be interfering with

achieving a higher level of performance from your process. What
actions are associated with these mental models?

– Describe an alternative mental model for each that could enhance the
improvement of your process. What actions are associated with the
alternative mental model?

12. Identify and apply any additional quality improvement tools (see
chapter 12) that may help you better understand how to improve your
process. Show your work.

13. If your process is to be the best practice for the community, describe
your ideal vision for this process. To help create your vision, ask yourself
the following questions:
– What would your process contribute to the overall organizational

performance or effectiveness?

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
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305Pract ice Lab 305

– What would patients and families who are receiving care as a result of
your process, or who are influenced by your process, say about their
experience with your organization?

– What would employees involved in your process say about the
process?

– What would colleagues around the country who came to learn from
your best practice say about your process?

14. Improve your process.
– Determine if you are solving a problem associated with an existing

process or creating a new process.

– Review your original and revised improvement goal(s).

– Review the purpose of your process.

– Review your customers’ expectations.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
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Applying Qual i ty Management in Healthcare: A Systems Approach306306

– Review the mental models you selected.

– Review what you learned from question 12.

– Redefine the starting and ending points of your process as needed to
support the purpose.

– Based on the previous information, document the ideal process that
will achieve the purpose you described, using a high-level flowchart.

– Check your process against the goal you set for your improvement
effort.

15. Review the measure from question 9. Is this measure still appropriate
for your ideal process? If not, what should you measure?

16. Review your goal and your purpose. Will these measure(s) help you
determine if you are working toward your goal and carrying out your
purpose?

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
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307Pract ice Lab 307

17. Describe any unintended consequences to any other area, department,
process, or entity inside or outside of your organization if you change
your process. What measure(s) would help you to be on the alert for
them?

18. Describe how the measures from questions 15 and 17 fit into a
balanced set of performance measures for the organization.

19. For your defined performance measures, describe
– How you would collect the data

– What type of graph you would use to report the data

– How often you would report the data

– With whom and how you would share the data for review on a
regular basis

20. You have defined the purpose and described the ideal process.
Determine the ideal structure to carry out this process—that is, by
whom and how the process should be carried out to best achieve the
purpose.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
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21. Describe an implementation plan that takes into consideration the
concepts described in chapter 12.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
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309309

PRACTICE EXERCISE 8: TEAMWORK AND
PATIENT SAFETY

Objective

To better understand how inadequate teamwork practices can cause a sentinel
event and what needs to be done to prevent similar events from occurring.

Instructions

1. Common teamwork barriers that can lead to a sentinel event include
these problems:
– Inconsistency in team leaders
– Lack of time to meet and interact as a team
– Hierarchy
– Defensiveness
– Not speaking up
– Conventional thinking
– Varying communication styles
– Unresolved conflict
– Distractions
– Fatigue
– Heavy workload
– Misinterpreting cues
– Lack of role clarity

Source: M. Leonard, A. Frankel, T. Simmonds, and K. Vega. 2005. Achieving
Safe and Reliable Healthcare: Strategies and Solutions. Chicago: Health
Administration Press.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.
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